Boston Medical Center. Injury Prevention Center

Transcription

1 Boston Medical Center Injury Prevention Center ANNUAL REPORT 2013

2 OUR MISSION The Injury Prevention Center (IPC) conducts and facilitates research on the causes, treatment and prevention of violence-related and unintentional injuries and promotes inter-disciplinary collaboration across academic and clinical disciplines, research and teaching institutions and legislative, regulatory and policy-making entities. Through education, research and advocacy, the IPC fosters engagement in injury research among students, clinicians and researchers. Front cover photo: 2011 Dave Steger

3 Jonathan S. Olshaker, MD Dear Friends, We are pleased to present the 2013 annual report of the Boston Medical Center (BMC) Injury Prevention Center. Under the continued leadership of Executive Director Jonathan Howland, PhD, MPH, MPA, the Center brings together the Department of Emergency Medicine, Department of Surgery, Division of Acute Care and Trauma Surgery and many BMC, Boston University School of Medicine (BUSM) and Boston University School of Public Health (BUSPH) faculty and staff with the combined mission of injury prevention, research, education and advocacy. This report highlights our programs focusing on violence intervention, substance abuse treatment, harm reduction and fall prevention as well as many others that are making significant contributions to local, national and international injury prevention. Sincerely, Peter A. Burke, MD Jonathan S. Olshaker, MD Chief and Chair, Department of Emergency Medicine Boston Medical Center, Boston University School of Medicine Peter A. Burke, MD Chief, Trauma Services, Boston Medical Center Professor of Surgery, Boston University School of Medicine A UNITED VISION The BMC Injury Prevention Center (IPC) was founded in July 2010 with support from the Department of Emergency Medicine and the Division of Trauma Surgery. This joint investment reflects a commitment to expand the missions of each to develop a viable, self-sustaining, long-term institution for injury prevention research and practice. The IPC was founded on the shared belief that: Many of the injuries treated at BMC are preventable Treatment should include intervention to prevent subsequent injury There is increasing evidence of the effectiveness of Emergency Department (ED)-based brief behavioral interventions BMC is positioned to become a nationwide leader in injury prevention research and intervention. THE INJURY PREVENTION CENTER AT BOSTON MEDICAL CENTER PAGE 1

4 LEADERSHIP COMMITTED TO IMPROVING LIVES The IPC staff brings together a wealth of combined experience to create a world-class center for research and training in the field of injury prevention and education. The leadership team of the IPC includes: Jonathan Howland, PhD, MPH, MPA IPC Executive Director and Professor of Emergency Medicine at BUSM. Dr. Howland has 25 years of experience in injury research with emphasis on traffic safety, older adult falls and alcohol s contribution to error in safety sensitive occupations. His research includes epidemiological studies of risk factors for burns, falls, traffic injuries, drowning and non-combat military injuries and experimental trials of interventions for traffic safety. His work also includes randomized alcohol administration trials on the acute occupational and neurocognitive effects of low-dose alcohol consumption and next day effects of intoxication. Dr. Howland has published many peerreviewed papers and book chapters, primarily focused on injury causation and control. For 20 years he taught program evaluation research methods at BUSPH. Lisa Allee, MSW, LICSW IPC Director of Programs and Education. Ms. Allee is an Instructor at BUSM, as well as the Injury Prevention Coordinator for BMC s Level-1 trauma center where she develops, monitors and maintains evidence-based injury prevention initiatives. Her clinical background spans 10 years as BMC s Pediatric and Pediatric Intensive Care Unit (ICU) Social Worker, where she specialized in the care of trauma patients and their families during their time in the ICU, as well as end of life care. Ms. Allee is also a faculty member of the BNI-ART Institute, providing training on SBIRT. Her clinical research interests involve life-long injury prevention. Current projects include research on older adult driving and safe sleep practices for infants and toddlers. Projects on Post Traumatic Stress Disorder and depression among trauma/acute care surgical patients and injury recidivism are in development. Ed Bernstein, MD IPC Director of Research, Director of the Section of Public Health at BMC and Professor and Vice Chair for Academic Affairs in Emergency Medicine at BUSM. Dr. Bernstein founded the BNI-ART Institute, which provides training and technical assistance to health care researchers and practitioners for implementing screening and brief intervention and behavioral change strategies. He is a founding member of the National Network of Hospital Violence Intervention Program (NNHVIP), the New England Violence and Injury Research Collaborative Network and the BMC Injury Prevention Center. Dr. Bernstein also is a member of the Suicide Prevention Resource Center s Emergency Department Consensus Panel. Emily Rothman, ScD Senior Scientist for Interpersonal Violence. Dr. Rothman is an Associate Professor at BUSPH with a secondary appointment in the Department of Pediatrics at BUSM. She also is a visiting scientist at the Harvard Injury Control Research Center. Her primary research focus is the prevention of youth dating violence, with additional research projects on the topics of adult partner violence, sexual violence, and the impacts of adolescent exposures to alcohol, marijuana or pornography. Thea James, MD IPC Director for Community Outreach, Director of the BMC Violence Intervention Advocacy Program and BUSM Associate Professor of Emergency Medicine. Dr. James is a founding member of NNHVIP and in 2008 was awarded the Boston Public Health Commission s Mulligan Award for Leadership and Public Service. Her international humanitarian efforts include educational outreach and disaster relief efforts in Haiti, India and Ghana. Dr. James is a Supervising Medical Officer on the PAGE 2 INJURY PREVENTION RESEARCH, EDUCATION AND ADVOCACY

5 MA-DMAT Team 1. In October 2011 she was selected as one of 12 members of the Attorney General s National Task Force on Children Exposed to Violence, which is part of a broader Defending Childhood Initiative. Kerrie Nelson, PhD IPC Biostatistician. Dr. Nelson s statistical interests lie in developing and applying statistical methods for diagnostic testing. Dr. Nelson provides statistical support to investigators in BMC s Department of Emergency Medicine and is working on many projects with medical and public health researchers at Boston University related to the Framingham Heart Study and diabetes. Originally from New Zealand, she received her PhD in Statistics from the University of Washington in Seattle. Maria Pantages Ober Director of Communications for BMC and BUSM. In conjunction with hospital and university leadership, Ms. Ober is responsible for executing a comprehensive and coordinated communications program for both BMC and BUSM, which includes 24-hour emergency communications and incident response. She began her career as a sportswriter, and worked for various newspapers and wire services throughout the country for 10 years, including USA Today and the Associated Press. She then transitioned into health care and higher education, a field she has worked in for the past 24 years, the last nine at BMC and BU. Among her personal and professional interests is promoting BMC as a leader in the fields of emergency medicine, trauma and injury prevention. Nicole Treadway, BA IPC Research Assistant. Ms. Treadway has a BA in Experimental Psychology from Vanderbilt University and recently completed a pre-medical post-baccalaureate program at Tufts University. To prepare for a career in medicine as a physician, and as an advocate for preventive care, she joined the IPC to help develop and implement a research program aimed at identifying and evaluating injury prevention policies and interventions. WELCOME As we continue to grow and evolve, in addition to welcoming Dr. Rothman to the leadership team, we are pleased to welcome the following professionals to the IPC organization. Robert A. Stern, PhD Professor of Neurology and Neurosurgery, BUSM; Co-Director, Alzheimer s Disease Clinical & Research Program, BUSM. Dr. Stern joins the IPC as a Senior Scientist for Traumatic Brain Injury. Ziming Xuan, ScD, SM, MA Assistant Professor, Community Health Science, BUSPH. Dr. Xuan brings to the IPC expertise on statistical analysis of injury prevention policy. THE INJURY PREVENTION CENTER AT BOSTON MEDICAL CENTER PAGE 3

7 CARING FOR VICTIMS OF TRAUMA We must reduce the number of homicides and shootings and take the illegal guns off our streets. But we must also take on the less visible but no less significant effects of violence: the trauma that too many Boston families experience. Boston Mayor Martin J. Walsh, 2014 The World Health Organization (WHO) has recently affirmed that all victims of violence should receive intervention for the prevention of traumatic stress disorders and that intervention should be based on personal and/or group counseling, as opposed to medications, which may mask, but not cure, psychological distress following trauma. BMC, which treats an average of 500 victims of penetrating trauma per year, has been a national leader in providing services to these patients. BMC programs currently include the Violence Intervention Advocacy Program (VIAP), led by Program Director Thea James, MD, which offers violence victims peer support and wraparound services such as education, housing, legal assistance and employment; and the Community Violence Response Team (CVRT), led by Program Director Lisa Allee, MSW, which provides violence victims with counseling by trained adult and child trauma mental health professionals. Acknowledging BMC s leadership in efforts to break the cycle of violence, days after his 2014 inauguration Mayor Martin J. Walsh visited Boston Medical Center to participate in a roundtable discussion with BMC President & CEO Kate Walsh, the City s Chief of Health and Human Services Felix Arroyo, Executive Director of the Boston Public Health Commission Barbara Ferrer, Boston Mayor Martin J. Walsh (right) visits BMC to meet with leaders Jonathan Olshaker, MD, Professor and Chair of Emergency Medicine (left); Kate Walsh, BMC President and CEO, and Barbara Ferrer, PhD, MPH, MEd, Executive Director of the Boston Public Health Commission. and several members of BMC s VIAP team. In his first press conference, Mayor Walsh pledged to address trauma and violence early in his term. The current BMC violence prevention programs aim to reduce subsequent hospital visits for violence-related injury and symptoms of trauma-related stress. Some level one trauma centers in Massachusetts and elsewhere in the US offer social and mental health services to violently injured patients, although such programs are rarely offered together in coordination, and neither program is offered universally. Thus, health care is just beginning to acknowledge the importance of comprehensive care for traumatized patients. The IPC envisions the development of a model of comprehensive care for trauma patients at BMC. Through the development and implementation of VIAP and CVRT, we have learned that a third and essential component of comprehensive care for victims of violence involves the compassion, understanding and support they receive from the clinicians involved in their care. The quality of clinician-patient interaction can affect patient experience and health outcomes in several respects. First, clinical decisions, such as administration of pain medications, can be influenced. Second, patients willingness to adhere to therapeutic regimens can be affected. Most importantly, however, a lack of trust and respect in patient-clinician interaction can reduce the effectiveness of programs, such as VIAP and CVRT, which aim to leverage the patient s trauma to create an opportunity for positive change in the patient s post-discharge life. Thus, improving service delivery across medical fields through trauma-informed care is a necessary component in a viable model of comprehensive care for violently injured patients. To address this important aspect of patient care, IPC Core faculty members are working to acquire funding and prioritize the development of trauma-informed care training modules for providers that interact with all of BMC s violently injured patients. THE INJURY PREVENTION CENTER AT BOSTON MEDICAL CENTER PAGE 5

8 FIGHTING THE OVERDOSE EPIDEMIC We have an epidemic of opiate abuse in Massachusetts, so we will treat it like the public health crisis it is. Massachusetts Governor Deval Patrick In Massachusetts and other states, opioid overdose is the leading cause of injury-related death, exceeding even traffic fatalities. For many years, heroin addiction has been a problem in the region. But since the introduction of powerful prescription pain medications, the rate of overdose has accelerated. In 2002, 844 people were hospitalized for opioid overdose in Massachusetts, doubling to 1,857 by In 2014, Gov. Patrick declared the opioid overdose epidemic a public health emergency. Opioids kill by affecting brain receptors that control critical functions, such as respiration and blood pressure. Naloxone is a drug that has been used to treat overdose in emergency rooms. It works by interrupting the bonds between opioids and brain receptors. Naloxone is non-addicting, does not cause euphoria and is relatively safe and easy to administer. Many victims of overdose, however, die before reaching the emergency room. Two IPC faculty members, Drs. Bernstein and Walley, have been active in developing and evaluating programs to increase the use of Naloxone for treatment of overdose. Pilot Program. This innovative program disseminates Naloxone to non-medical personnel and trains them to administer it in the field to overdose victims. Individuals trained in Naloxone administration include drug users, their family members, first responders, and community health workers. Since its start in 2007, the program has trained more than 200,000 people in the use of Naloxone and it is estimated that the program has reversed overdose in over 2,000 events. Dr. Bernstein has implemented a program in which Health Promotion Advocates employed by Project ASSERT (BMC s substance screening and intervention program) train BMC patients who are opioid users in Naloxone administration for overdose victims in the community. IPC core faculty members are committed to further research and program development for overdose prevention. Continued results of these efforts are presented at key conferences both locally and nationally. Dr. Walley leads the Massachusetts Department of Public Health s (MDPH) Opioid Overdose Prevention Non-addicting Naloxone is used in emergency rooms to treat drug overdose. PAGE 6 INJURY PREVENTION RESEARCH, EDUCATION AND ADVOCACY

9 FOCUS ON FALLS Falls can cause moderate to severe injuries, such as hip fractures and head traumas, and can increase the risk of early death. Fortunately, falls are a public health problem that is largely preventable. Centers for Disease Control and Prevention Older adult falls are a serious and growing public health problem in Massachusetts and the nation. Thirty percent of those age 65 years and older experience at least one fall each year and many fall repeatedly. In Massachusetts, as elsewhere in the US, falls are the leading cause of injury-related deaths and non-fatal injuries among older adults. Furthermore, fall injuries are increasing. Though in part this is due to an aging population, the age-adjusted risk for fall injuries is increasing as well. The costs of treatment for older adult falls are substantial. In Massachusetts in 2010 the amounts spent for treatment of falls were: $512 million for hospital admissions $100 million for Emergency Department visits $19 million for observation stays Total $631 million Fortunately, there is increasing awareness among older adults, their adult children and health care providers that risk for falls can be reduced. Several decades of research indicate that both clinical multifactorial assessments, as well as low cost community-based programs, can reduce falls risk by 25-30%. In partnership with MDPH, several local municipalities, and other public agencies, IPC staff has been actively involved with falls prevention research and program development. Recently, Governor Duval Patrick appointed a Massachusetts Falls Prevention Commission, the first of its kind in the nation. The IPC was engaged by the Commission to conduct a state-wide survey of community-based falls prevention programs conducted 434 Deaths 21,375 Hospital Stays 40,091 Emergency Department Visits Distribution of falls related injuries among Massachusetts older Adults, 2010 by organizations that serve Massachusetts older adults. The Commission will use these data to develop a statewide strategic plan for older adult fall prevention. In a companion study commissioned by the MDPH, the IPC will survey a sample of Massachusetts primary care physicians regarding their current practices for assessing and treating falls risk among their older adult patients. In conjunction with the Massachusetts Prevention and Wellness Trust Fund (P&WTF), two IPC faculty are assisting communities in developing referral systems that will link healthcare providers with local organizations that offer fall prevention programing. Dr. Howland is working with the City of New Bedford and Dr. Shankar is working with the Boston Public Health Commission (BPHC). Dr. Howland is also working with the state DPH to develop evaluation metrics for five other municipalities receiving P&WTF grants for falls prevention. THE INJURY PREVENTION CENTER AT BOSTON MEDICAL CENTER PAGE 7

10 Here at BMC, Drs. Howland and Shankar and Nicole Treadway are conducting a study of fall prevention services received by older adults within two months of their discharge from the BMC Emergency Department after treatment for a fall-related injury. This is the first study to document the extent to which this population of older adults who are at high-risk for subsequent falls are assessed by their primary care physicians or are otherwise engaged in fall prevention programs and activities. In addition, with funding from the Tufts Health Foundation, Lisa Allee, IPC Director of Programs & Education, is facilitating a fall-prevention program at The Harriet Tubman House, a local community center. The program, A Matter of Balance, aims to reduce fear of falls and promote fall prevention strategies among older adults. Patients who are treated for falls at the BMC Emergency Department receive information on this program when they are discharged. Finally, Allee and Peter Burke, IPC Co-founder, have conducted a study for the Centers for Disease Control and Prevention (CDC) to determine the circumstances under which Emergency Medical Services (EMS) patients were transported to emergency departments and to identify opportunities for fall prevention among transported and non-transported patients. Together, these initiatives by IPC faculty are making a substantial contribution to the deployment of clinical and community-based falls prevention throughout Massachusetts. RESEARCH PROJECTS Moving into its fourth year, the IPC continues to expand its mission to research causes, treatment and prevention of violence-related and unintentional injuries. PROGRAM EVALUATION Evaluation of Massachusetts Core Injury Prevention Grant (Howland, Treadway): The IPC was selected by the MDPH as the external evaluator for the State s CDC-funded Core Injury Prevention Grant. The department s five-year injury prevention strategic plan, which began in August 2011, targets opioid overdose, older adult falls, sports concussion among young people, infant safe sleep, and vehicular injuries. OLDER ADULT FALLS State-Wide Community Falls Prevention Program Inventory (Howland, Treadway): In collaboration with the MDPH and the newly established Massachusetts Commission on Falls Prevention, the IPC will conduct a statewide survey of organizations and agencies that serve older adults. The goal is to develop an inventory of current evidence-based, community fall prevention programs that characterizes programs regarding facilitator training and qualifications, cost to participants, and number of older adults served. Statewide Tai Chi Training Program for Falls Prevention (Howland, Treadway): As part of a strategy to enhance infra-structure for community-based falls prevention programs, the MDPH sponsored a series of trainings in a CDC-approved Tai Chi program designed to reduce older adult falls by enhancing strength and balance. Three regional trainings were sponsored across the state, with a total of 40 trainees. The IPC PAGE 8 INJURY PREVENTION RESEARCH, EDUCATION AND ADVOCACY

11 is evaluating the program with regard to program participation, characteristics and relevant expertise of trainees; trainee satisfaction with the program; number of Tai Chi classes and number of attending older adults during the post-training year. Falls Follow-up Study (Howland, Shankar, Treadway) Falls are common among older adults and account for approximately 2.3 million ED visits nationally per year. The BMC ED treats approximately older adult fall patients per week. Although there is abundant evidence that clinical and community-based fall reduction interventions are effective, there is little information on the uptake of falls prevention behaviors among community dwelling older adults who have experienced a fall requiring medical attention. This study aims to pilot a larger investigation that addresses this gap in the literature and characterizes fall prevention behaviors, especially engagement with primary care physicians, and covariates of these behaviors. Findings could eventually inform discharge protocols for older adults who have been treated for falls at EDs or outpatient services. Factors that Impact Transport by EMS Providers Following Falls Among Older Adults (Allee, Burke): Among people age 65 and older, falls are the leading cause of Emergency Department visits for injury and injury-related deaths. Emergency Medical Services (EMS) are often called to help older adults who have fallen, with some proportion requiring hospital transport. There are few estimates on the proportion of people who are not transported by EMS. This study provides insight into how fall circumstances and locations are associated with the likelihood that a patient will be transported to a hospital. For the approximate 17.5% of fallers who are not transported, EMS personnel are in a prime position to provide information aimed at preventing future falls. INTERPERSONAL VIOLENCE VIAP Qualitative Evaluation Project (James, Dugan, Langlois, Bibi, Mitchell): VIAP is a BMC program that provides victims of intentional violence with assessment, counseling, case management, and referral for clinical and social services. This qualitative study was designed to contextualize the experience of VIAP clients and to better understand their perceptions of the program s impact on their lives. Post Traumatic Stress Symptoms (PTSS) and Recidivism in Trauma Patients (Allee, Howland, Treadway): A pilot study to assess whether Post Traumatic Stress Symptoms (PTSS) among intentionally injured trauma service patients predict subsequent ED visits for violence-related injury, it will use data from a previous investigation of the prevalence and covariates of PTSS in patients admitted to the BMC trauma service in That study found that 16% of patients screened positive for PTSS and that this condition was strongly associated with intentional injury. In the proposed study we will determine the 5-year intentional injury recidivism rates for the previous study participants who were intentionally injured and did or did not have PTSS. Interpersonal Injury: Risk Factors and Recidivism (Burke, Allee, Howland): There is limited research on the recidivism rates of lower-level interpersonal violence injuries (e.g., assaults) that are seen, treated and released from the Emergency Department. This study will use a retrospective analysis of a cohort of 1,500 patients who presented at the BMC ED for intentional injuries to determine risk factors and recidivism rates for violent injury and to examine whether there are trends in injury severity escalation five years post discharge. THE INJURY PREVENTION CENTER AT BOSTON MEDICAL CENTER PAGE 9

12 Uptake of CVRT Mental Health Services among Violently Injured Patients Treated at Boston Medical Center (Allee, Burke, Howland, Treadway): Recently the World Health Organization recommended that all medically treated victims of violence be offered mental health services to reduce the psychological effects of trauma. They recommended that these services include talk therapy, as opposed to medications, which might relieve symptoms temporarily, but do not address the underlying trauma. BMC offers mental health counseling to trauma victims via the CVRT, which includes master s degree-level counselors with experience in child and adult trauma counseling. For these services to be effective, however, patients must engage in counseling or follow-up on referrals for additional mental health services. The aim of this study is to determine the rate of uptake of CVRT services among violently injured patients treated at BMC and the characteristics of patients who do and do not participate in the CVRT program. Safe Zones and Danger Zones: A Geographic Study of Violence and Associated Resilience Factors in the Urban Environment (Myers): Violence is one of the leading causes of preventable death of young adults living in urban areas. However, this violence is not distributed uniformly. This study aimed to better understand how resilience factors associated with less violence can influence city planning outreach programs combating violence. Results indicated strong associations between violence/security and family structure, non-vacant housing, education and access to public transit. Domestic Violence Prevention Enhancements and Leadership Through Alliances, Focusing on Outcomes for Communities United with States (DELTA FOCUS) (Rothman, Marbach): DELTA FOCUS is a five-year, cooperative agreement funding 10 state domestic violence coalition grantees (including The Rhode Island Coalition Against Domestic Violence) to engage in primary prevention of intimate partner violence. The Rhode Island Coalition Against Domestic Violence will work alongside it s local sub-grantees, The Elizabeth Buffam Chace Center in Cranston, RI, and The Women s Resource Center in Newport, RI, to implement and evaluate intimate partner violence prevention programming. The goals of DELTA FOCUS include: Identify promising prevention strategies and describe them using case studies Promote the prevention of intimate partner violence Create a foundation for building practice-based evidence for intimate violence prevention programming The Temporal Relationship between Youth Drinking and Dating Violence Perpetration (Rothman): The aims of this project are to use an innovative data collection method, Interactive Voice Response (IVR), to collect daily reports on alcohol use and dating violence from 80 urban, primarily low-income and non-white adolescents over a 12-week period. The study will provide feasibility data about the use of IVR to collect sensitive information from a hardto-reach population, will yield information about the sequence of events on days when participants drink and perpetrate dating violence, and will compare event data collected via IVR and timeline follow back for the same time period. A Brief Intervention to Prevent Adolescent Dating Aggression Perpetration (Rothman): The aim of this study is to test the efficacy of a brief motivational interview-style intervention to prevent the perpetration of dating aggression by youth. This study will use a randomized controlled trial design, enroll 334 youth age years old, and take place in an urban emergency department setting. Underage alcohol use and dating abuse perpetration (Rothman): The aims of this project are to test a conceptual framework of the relationship between underage alcohol consumption and dating abuse perpetration; develop an emergency departmentbased intervention to reduce underage alcohol use and dating abuse perpetration; and pilot test the efficacy of the intervention. PAGE 10 INJURY PREVENTION RESEARCH, EDUCATION AND ADVOCACY

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